A novel risk score for severe ARDS patients undergoing ECMO after retrieval from peripheral hospitals

Abstract

Background: Extracorporeal Membrane Oxygenation in severe ARDS unresponsive to conventional protective ventilation is associated with elevated costs, resource and complications, and appropriate risk stratification of candidate patients could be useful to recognize those more likely to benefit from ECMO. We aimed to derive a new outcome prediction score for patients retrieved by our ECMO team from peripheral centers, including systematic echocardiographic evaluation before ECMO start. Methods: Sixty-nine consecutive patients with refractory ARDS requiring ECMO transferred from peripheral centers to our ICU (a tertiary ECMO referral center), from 1 October 2009 to 31 December 2015, were assessed. Results: All patients were transported on ECMO (distance, median 77, range 4-456 km) The mortality rate was 41% (28/69). Our new risk score included age ≥ 42 years, BMI < 31 kg/m 2 , RV dilatation, and pH < 7.35. The proposed cut off (Youden's index method) of nine had a sensitivity of 96% and a specificity of 30% (AUC-ROC: 0.85, 95% CI: 0.76-0.94, P < 0.001). When assessing the discriminatory ability of our risk score in the population of local patients, survivors had a mean value of 15.4 AE 8.6, whereas non-survivors showed a mean value of 20.1 AE 7.4 (P < 0.001). Conclusions: Our new risk score shows good discriminatory ability both in patients retrieved from peripheral centers and in those implanted at our center. This score includes variables easily available at bedside, and, for the first time, a pathophysiologic element, RV dilatation.

The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation

“…The assessment of RV function and RV dimensions is important prior to initiating ECMO support, although the complex shape of the RV chamber makes it difficult to use geometric models for volume and function quantification, and the retrosternal position of the RV creates a barrier for ultrasound waves. The finding of RV dilatation pre-ECMO initiation has been associated with increased intensive care unit mortality ( 45 , 46 ). The aim of RV function assessment is to estimate RV pressure and demonstrate the presence and extent of ventricular dysfunction.…”

Prognostic models for mortality risk in patients requiring ECMO

“…Of 58 developed models, 21 (15 articles) [9,11,13,[21][22][23][24][25][26][27][28][29][30][31][32] and 31 (29 articles) [10, 12, 14-16, 30, 33-57] were derived from ECMO recipients suffering from respiratory and cardiocirculatory failure, respectively. Six other models (in two studies) were derived in a mixed cohort [58,59].…”

A Mortality Prediction Score for Patients With Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): The PREDICT VV-ECMO Score

“…A team of experienced intensivists defined primary relevant factors known or suspected to be associated with patient mortality after review of the literature. 9,11,12,14,22,[25][26][27][28][29] Both clinical relevance and practicability of collecting these parameters in clinical routine were considered. Therefore, the primary parameter selection was driven clinically, no data-driven variable selection was conducted.…”